How To Complete The 10-Year Employment History Background Verification Log

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HOW TO COMPLETE THE 10-YEAR EMPLOYMENT HISTORY
BACKGROUND VERIFICATION LOG
Items to be submitted for 10-year employment history background verification:
Return the checklist, log and corresponding documentation to the Security Badge Office within 30 days.
Signed and dated Background Verification Checklist
Employment History Log(s) listing the last 10 years of employment and/or education with all 10 years verified by the
employer
Attach all submitted proof of employment / school verification. (I.e. letter, transcript, facsimile, unemployment
o
receipts, taxes, etc…)
Original, valid government issued photo identification
Certified birth certificate or passport, along with a certified translation if not in English – original will be verified at the
Security Badge Office and returned
If the individual is a foreign national, the individual must present a current and valid work visa or other equivalent
document
Instructions:
Type or print all information legibly.
Applicant Name: Print applicant’s full name as it appears on valid government identification
Aliases: Print any other legal names by which the applicant may be known
Social Security Number: Print applicant’s complete social security number
Date of Birth: Print applicant’s full birth date (mm/dd/yyyy)
Authorized Signer and Email: Print the name of the authorized signer and a contact email address, for the signer who will serve
as the primary contact during this process
Organization Name and Organization Code: Print the full company name and organization code
Page # of #: Print the page number, then the total number of pages attached
Dates of employment, education or unemployment (list most recent first) (EMPLOYEE): Beginning with the current position, list a
complete account of the last 10 years. Do not leave any gaps of time
Name and address of each employer, school, or note circumstances if not employed for 30 days or more (EMPLOYEE): Write
the full name and complete address of each employer or school the employee has attended. If the employee was
unemployed for 30 days or more at any time during the last 10 years, your company must provide documentation of this gap
Full name, title, organization, and telephone number of person confirming background information (COMPANY): Write in the
full name, title, full company name, phone number (with area code), and email of the person who is confirming the
background information as listed on the employment history background verification log
Full name, title, organization, and telephone number of person conducting background information (if not the authorized
signer)(COMPANY): Write in the full name, title, phone number (with area code), and email of the person who is performing
the background verification, if it is not the same as the authorized signer listed at the top of the log
Method of Verification (telephone, fax, letter, etc.)(COMPANY): Check the method of verification used
Date and time of verification (COMPANY): Print complete date and time the information was verified
At the bottom of the form provide the authorized signer’s signature, organization code, contact information and the date and
time the log was completed.
IF THE VERIFICATION LOG IS NOT COMPLETE, IT WILL BE RETURNED FOR ADDITIONS AND/OR CORRECTIONS.

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